Principles of Forensic Engineering Applied to Industrial Accidents

An introductory text on the investigation of industrial accidents Forensic engineering should be seen as a rigorous approach to the discovery of root causes that lead to an accident or near-miss. The approach should be suitable to identify both the immediate causes as well as the underlying factors that affected, amplified, or modified the events in terms of consequences, evolution, dynamics, etc., as well as the contribution of an eventual "human error". This book is a concise and introductory volume to the forensic engineering discipline which helps the reader to recognize the link among those important, very specialized aspects of the same problem in the global strategy of learning from accidents (or near-misses). The reader will benefit from a single point of access to this very large, technical literature that can be only correctly understood with the right terms, definitions, and links in mind. Keywords: Presents simple (real) cases, as well as giving an overview of more complex ones, each of them investigated within the same framework; Gives the readers the bibliography to access more in-depth specific aspects; Offers an overview of the most commonly used methodologies and techniques to investigate accidents, including the evidence that should be collected to define the cause, dynamics and responsibilities of an industrial accident, as well as the most appropriate methods to collect and preserve the evidence through an appropriate chain of security. Principles of Forensic Engineering Applied to Industrial Accidents is essential reading for researchers and practitioners in forensic engineering, as well as graduate students in forensic engineering departments and other professionals.

Table of Contents:
Foreword by Giomi xiii Foreword by Chiaia xv Foreword by Tee xvii Preface xix Acknowledgement xxi List of Acronyms xxiii 1 Introduction 1 1.1 Who Should ReadThis Book? 1 1.2 Going Beyond theWidget! 2 1.3 Forensic Engineering as a Discipline 5 References 7 Further Reading 7 2 Industrial Accidents 9 2.1 Accidents 9 2.1.1 Principles of Combustion 14 2.1.1.1 Flammable Gases and Vapors 17 2.1.1.2 Flammable Liquids 21 2.1.1.3 The Ignition 22 2.1.2 Fires 23 2.1.3 Explosions 27 2.1.4 Incidental Scenarios 33 2.2 Near Misses 39 2.3 Process Safety 40 2.3.1 Management of Safety 41 2.4 The Importance of Accidents 47 2.4.1 Seveso disaster 48 2.4.2 Bhopal Disaster 51 2.4.3 Flixborough Disaster 55 2.4.4 Deepwater Horizon Drilling Rig Explosion 58 2.4.5 San Juanico Disaster 60 2.4.6 Buncefield Disaster 64 2.5 Performance Indicators 68 2.6 The Role of ‘Uncertainty’ and ‘Risk’ 72 References 75 Further reading 78 3 What is Accident Investigation?What is Forensic Engineering?What is Risk Assessment?Who is the Forensic Engineer and what is his Role? 79 3.1 Investigation 79 3.2 Forensic Engineering 87 3.3 Legal Aspects 91 3.4 Ethic Issues 95 3.5 Insurance Aspects 96 3.6 Accident Prevention and Risk Assessment 98 3.6.1 “What-if ” Analysis 100 3.6.2 Hazard and Operability Analysis (HAZOP) & Hazard Identification (HAZID) 101 3.6.3 Failure Modes and Effects Analysis (FMEA) 105 3.7 Technical Standards 105 References 112 Further Reading 113 4 The Forensic EngineeringWorkflow 115 4.1 TheWorkflow 115 4.2 Team and Planning 118 4.3 Preliminary and Onsite Investigation (Collecting the Evidence) 124 4.3.1 Sampling 127 4.3.1.1 Selection of the Sample 127 4.3.1.2 Collection of the Sample 128 4.3.1.3 Packaging of the Sample 129 4.3.1.4 Sealing the Packaging 130 4.4 Sources and Type of Evidence to be Considered 130 4.4.1 People 133 4.4.1.1 Conducting the Interview 136 4.4.2 Paper Documentation 138 4.4.3 Digital Documentation and Electronic Data 140 4.4.3.1 An Example about the Value of Digital Evidence 141 4.4.4 Physical Evidence 145 4.4.5 Position Data 146 4.4.6 Photographs 147 4.4.6.1 The Collection of the Photographs 148 4.4.6.2 Photograph Cataloguing 150 4.5 Recognise the Evidence 152 4.5.1 Short Case Studies 155 4.5.1.1 Explosion of Flour at the Mill of Cordero in Fossano 156 4.5.1.2 Explosion at the Pettinatura Italiana Plant 157 4.5.1.3 Explosion of the Boiler of the SISAS Plant of Pioltello 160 4.5.1.4 Explosion of the Steam Generator of the Plant Enichem Synthesis at Villadossola 163 4.5.1.5 Aluminium Dust Explosion at Nicomax in Verbania 163 4.6 Organize the Evidence 166 4.7 Conducting the Investigation and the Analysis 168 4.7.1 Method of the Conic Spiral 172 4.7.2 Evidence Analysis 173 4.8 Reporting and Communication 175 References 180 Further Reading 182 5 Investigation Methods 183 5.1 Causes and Causal Mechanism Analysis 183 5.2 Time and Events Sequence 192 5.2.1 STEP Method 196 5.3 Human Factor 199 5.3.1 Human Error 204 5.3.2 Analysis of Operative Instructions andWorking Procedures 208 5.4 Methods 212 5.4.1 Expert Judgment and Brainstorming 213 5.4.2 Structured Methods and Approaches 214 5.4.2.1 Pre-structured Methods 218 5.4.2.2 Barrier-based Systematic Cause Analysis Technique (BSCATTM) 222 5.4.2.3 Tripod Beta 228 5.4.2.4 Barrier Failure Analysis (BFA) 232 5.4.2.5 Root Cause Analysis (RCA) 238 5.4.2.6 QRA derived tools 253 References 263 Further Reading 266 6 Derive Lessons 267 6.1 Pre and Post Accident Management 267 6.2 Develop Recommendations 274 6.2.1 An Application of Risk Analysis to Choose the Best Corrective Measure 284 6.3 Communication 290 6.4 Safety (and Risk) Management and Training 296 6.5 Organization Systems and Safety Culture 298 6.6 Behavior-based Safety (BBS) 303 6.7 Understanding Near-misses and Treat Them 304 References 307 Further Reading 308 7 CaseStudies 309 7.1 Jet Fire at a Steel Plant 309 7.1.1 Introduction 309 7.1.2 How it Happened (Incident Dynamics) 310 7.1.3 Why it Happened 314 7.1.4 Findings 321 7.1.5 Lessons Learned and Recommendations 322 7.1.6 Forensic Engineering Highlights 326 7.1.7 References and Further Readings 328 7.2 Fire on Board a Ferryboat 329 7.2.1 Introduction 329 7.2.2 How it Happened (Incident Dynamics) 330 7.2.3 Why it Happened 330 7.2.4 Findings 338 7.2.5 Lessons Learned and Recommendations 342 7.2.6 Forensic Engineering Highlights 342 7.2.6.1 The Discharge Activity and the Evidence Collection 342 7.2.6.2 Use of and Issues Regarding Digital Evidences 345 7.2.6.3 Expected Performances of the Installed DigitalMemories 348 7.2.6.4 The VDR (Voyage Data Recorder) System 348 7.2.6.5 Data Extraction from the “Black Box” (i.e.: FRM Module) 350 7.2.6.6 Analysis and Use of Extracted Data 351 7.2.6.7 Documentation Analysis of the Fire Detection System 352 7.2.7 References and Further Readings 354 7.3 LOPC of Toxic Substance at a Chemical Plant 354 7.3.1 Introduction 354 7.3.2 How it Happened (Incident Dynamics) 354 7.3.3 Why it Happened 355 7.3.4 Findings 358 7.3.5 Lessons Learned and Recommendations 363 7.3.6 Forensic Engineering Highlights 364 7.4 Refinery’s Pipeway Fire 366 7.4.1 Introduction 366 7.4.2 How it Happened (Incident Dynamics) 367 7.4.3 Why it Happened 371 7.4.4 Findings 373 7.4.5 Lessons Learned and Recommendations 375 7.4.6 Forensic Engineering Highlights 378 7.4.7 References and Further Readings 379 7.5 Flash Fire at a Lime Furnace Fuel Storage Silo 381 7.5.1 Introduction 381 7.5.2 How it Happened (Incident Dynamics) 382 7.5.3 Why it Happened 385 7.5.4 Findings 388 7.5.5 Lessons Learned and Recommendations 388 7.5.6 Forensic Engineering Highlights 388 7.5.7 Further Readings 388 7.6 Explosion of a Rotisserie Van Oven Fueled by an LPG System 389 7.6.1 Introduction 389 7.6.2 How it Happened (Incident Dynamics) 390 7.6.3 Why it Happened 394 7.6.4 Findings 398 7.6.5 Lessons Learned and Recommendations 399 7.6.6 Forensic Engineering Highlights 399 7.6.7 Further Readings 406 7.7 Fragment Projection inside a Congested Process Area 407 7.7.1 Introduction 407 7.7.2 How it Happened (Incident Dynamics) 408 7.7.3 Why it Happened 408 7.7.4 Findings 409 7.7.4.1 Collection of Evidences and Data 410 7.7.4.2 Initial Plate Velocity and Box Deformation 410 7.7.4.3 Development of a Piping Damage Criteria 415 7.7.4.4 Evaluation of Damages 421 7.7.4.5 Results for Impacts for Some Pipes 421 7.7.4.6 FI-BLAST© Adaptation to Perform a Parametric Study 422 7.7.4.7 Results of the Parametric Study 426 7.7.5 Lessons Learned and Recommendations 427 7.7.6 Forensic Engineering Highlights 428 7.7.7 References and Further Readings 429 7.8 Refinery Process Unit Fire 429 7.8.1 Introduction 429 7.8.2 How it Happened (Incident Dynamics) 429 7.8.3 Why it Happened 433 7.8.4 Findings 435 7.8.4.1 Examination of the Effects of the Fire 437 7.8.4.2 Water and Foam Consumption 438 7.8.4.3 Damages 438 7.8.5 Lessons Learned and Recommendations 438 7.8.6 Forensic Engineering Highlights 439 7.8.7 References and Further Readings 448 7.9 Crack in an Oil Pipeline 449 7.9.1 Introduction 449 7.9.2 How it Happened (Accident Dynamics) 450 7.9.3 Why it Happened 453 7.9.4 Experimental Campaign on the Pipeline Segment 453 7.9.5 Findings 457 7.9.6 Lessons Learned and Recommendations 460 7.9.7 Forensic Engineering Highlights 462 7.9.8 References and Further Readings 463 7.10 Storage Building on Fire 463 7.10.1 Introduction 463 7.10.2 How it Happened (Accident Dynamics) 464 7.10.3 Why it Happened 464 7.10.4 Findings 465 7.10.5 Lessons Learned and Recommendations 466 7.10.6 Forensic Engineering Highlights 467 7.10.7 Further Readings 467 8 Conclusions and Recommendations 469 References 471 9 A Look Into the Future 473 References 476 A Principles on Probability 477 A.1 Basic Notions on Probability 477 Index 479